自体脾移植及食管横断吻合术治疗肝硬化门脉高压症——免疫学及门静脉血流动力学观察

Effect of splenic autotransplantation combined with lower esophagus transection on immune functions and portal hemodynamics in hepatic cirrhosis with portal hypertension patients

目的评价自体脾移植及食管横断吻合术对肝硬化门静脉高压症(portal hypertension,PHT)术后的免疫功能和门脉血流动力学的影响。方法20例PHT随机分为2组,每组10人。均进行改良Sugiura手术,对照组做脾切除,自体研究组脾部分腹膜后移植。手术前后检测血清tuftsin和IgM。脾脏动态同位素99MTC显像。手术前后通过三维动态增强磁共振血管成像测量门静脉主干的管腔横截面、血流量、血流速度和流向;观察自体移植脾在腹膜后的血供及侧支循环。结果对照组术后血清tuftsin和IgM水平明显降低(tuftsin:P<0.001;IgM:P=0.04);脾自体移植组的血清tuftsin和IgM水平保持稳定(tuftsin:P=0.25;IgM:P=0.12)。研究组有4例病人在术后随访中移植脾块同位素显像呈阳性,而对照组无阳性显像。术后6个月2组MPV的管腔横截面积明显减少(研究组t=13.96,P=0.00;对照组t=11.38,P=0.00)。术后MPV的平均流速2组均较明显下降(研究组t=18.98,P=0.00;对照组t=22.32,P=0.00),且研究组少于对照组(t=-8.02,P=0.00)。术后MPV的平均流量2组均比较(研究组t=16.93,P=0.00;对照组t=15.90,P=0.00),且研究组少于对照组(t=-2.73,P=0.02)。移植脾在腹膜后成活,并建立了广泛的侧支循环。结论自体脾移植治疗肝硬化门脉高压症,不仅保留脾脏的免疫功能,且该术式起到断流和分流的作用。

Objective To investigate the effect of splenic autotransplantation combined with lower esophagus transection on immune functions and portal hemodynamics in hepatic cirrhosis with portal hypertension patients. Method 20 patients with liver cirrhosis complicated with portal hypertension were randomly allocated into 2 groups: splenic autotransplantation(n=10), in which patients underwent splenectomy with retroperitoneal splenic autotransplantation and gastroesophageal devascularization (modified Sugiura operation), and control group(n=10), in which only splenectomy and gastroesophageal devascularization were performed. Serum tuftsin and IgM were measeured. Dynamic scintigraphy with technetium 99mTC-labeled heat-damaged erythrocytes was performed. The cross section area, blood velocity and flow and collateral circulation of portal parameters were comparatively evaluated 3D DEC MRA, and the fragment, size, blood flow and collateral circulation of retroperitoneal transplanted spleen were comparatively assessed. Results The preoperative levels of serum tuftsin and IgM showed no statistical difference between groups. However, Serum tuftsin and IgM decreased remarkably in the control group (P<0.05) while that in splenic autotransplantation group remained stable. Autotransplantation group showed the transplanted splenic fragment during follow-up. At 6-month after operation, the cross section areas of MPV in both two groups significantly decreased (study group t=13.96, P=0.00; control group t=11.38,P=0.00). The mean blood velocity and the mean blood flow volumeof MPV after operation were lower (study group t=18.98,P=0.00; control groupt=22.32, P=0.00), and those in study group were lower than that in control group (t=-8.02, P=0.00). The transplanted spleen had extensive collateral circulation. Conclusions Partial splenic autotransplantation combined with lower esophagus transection in the treatment of hepatic cirrhosis complicated portal hypertension not only preserves splenic immune function, but also ploys a role in devascularization and shunting for portal hemodynamics.